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A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

Encourage physical activity prior to bedtime.

Replace the carpet with hardwood floors.

Wear clothing with zippers instead of buttons.

Place locks at the tops of exterior doors.

Answer and Explanation

The Correct Answer is D

A. Physical activity should be scheduled earlier in the day to prevent overstimulation and promote restful sleep.

B. Hardwood floors increase the risk of falls; carpets provide better traction and cushioning.

C. Zippers can be difficult for clients with Alzheimer's; clothing with Velcro or simple fasteners is preferred.

D. Placing locks at the tops of doors reduces the risk of wandering, a common safety concern in clients with Alzheimer's.

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Correct Answer is C

Explanation

A. Widened pulse pressure (not narrowed) is associated with increased ICP.

B. Bradycardia (not tachycardia) is commonly seen in increased ICP due to Cushing’s triad.

C. An increasingly severe headache is a key sign of rising ICP due to increased pressure on pain-sensitive structures.

D. Hypertension, not hypotension, is a characteristic of increased ICP.

A. Replace the indwelling urinary catheter. B. Perform the Credés maneuver. C. Maintain the irrigation solution rate. D. Warm the irrigation solution.

Correct Answer is C

Explanation

A. There is no need to replace the catheter unless it is obstructed or malfunctioning.

B. Credé’s maneuver is used for bladder emptying, not for continuous bladder irrigation.

C. Pink-tinged urine is expected in the first 24 hours after a transurethral resection of the prostate (TURP). The nurse should maintain the irrigation rate to prevent clot formation.

D. Warming the irrigation solution is not indicated.

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A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

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Correct Answer is C

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